What is the best course of treatment for an adult patient with a urinary tract infection (UTI) as indicated by a bacteria urinalysis result?

Treatment of Bacteria in Urinalysis (Code 151.02)

Do not treat bacteria in urinalysis without confirming the patient has specific urinary symptoms—the presence of bacteria alone, even with pyuria, represents asymptomatic bacteriuria in most cases and should not be treated. 1, 2

Critical First Step: Assess for Symptoms

Before any treatment decision, determine if the patient has acute onset of specific urinary symptoms 3:

• Dysuria (painful urination)
• Urinary frequency or urgency
• Fever >38.3°C (101°F)
• Gross hematuria
• Suprapubic pain
• Costovertebral angle tenderness (suggests pyelonephritis)

If the patient lacks these symptoms, this is asymptomatic bacteriuria and requires NO treatment in most populations. 1, 2

When Asymptomatic Bacteriuria SHOULD Be Treated

Only two populations require treatment of asymptomatic bacteriuria 2:

1. Pregnant women: Screen with urine culture in first trimester and treat with 3-7 days of antibiotics if positive 2
2. Patients undergoing urologic procedures with anticipated mucosal bleeding: Treat 30-60 minutes before procedure and discontinue immediately after unless catheter remains 2

All other populations—including elderly patients, diabetics, catheterized patients, and those with spinal cord injury—should NOT be treated for asymptomatic bacteriuria. 1, 2

If Patient HAS Symptoms: Confirm Diagnosis

For symptomatic patients, proper diagnosis requires 3:

• Pyuria: ≥10 WBCs/high-power field OR positive leukocyte esterase
• Proper specimen collection: Midstream clean-catch or catheterization to avoid contamination 3
• Urine culture: Obtain BEFORE starting antibiotics to guide therapy 3

The combination of negative leukocyte esterase AND negative nitrite has 90.5% negative predictive value and effectively rules out UTI 3.

First-Line Treatment for Confirmed Uncomplicated Cystitis

For symptomatic patients with confirmed UTI, use these first-line options 1:

Preferred agents:

• Nitrofurantoin 100 mg orally twice daily for 5 days 1, 4
• Fosfomycin trometamol 3 grams orally as single dose 1, 4
• Pivmecillinam 400 mg orally three times daily for 3-5 days 1

Alternative agents (only if local E. coli resistance <20%) 1:

• Trimethoprim-sulfamethoxazole 160/800 mg orally twice daily for 3 days 1, 5
• Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days) 1

Fluoroquinolones should be reserved as second-line therapy due to resistance concerns and adverse effects. 1, 4

Treatment Duration Considerations

• Uncomplicated cystitis: 3-7 days depending on agent 1, 3
• Men with UTI: 7 days minimum (cannot exclude prostate involvement) 1, 3
• Suspected pyelonephritis or febrile UTI: 7-14 days 3
• Pregnant women with asymptomatic bacteriuria: 3-7 days 2

Critical Pitfalls to Avoid

Do NOT treat based on 1, 3:

• Cloudy or malodorous urine alone
• Confusion or delirium in elderly patients without specific urinary symptoms
• Positive urine culture in catheterized patients without systemic symptoms
• Pyuria alone without symptoms

Treating asymptomatic bacteriuria causes harm 1, 2:

• Increases antimicrobial resistance (individual and community level)
• Increases risk of Clostridioides difficile infection
• Causes adverse drug reactions
• Provides NO clinical benefit (no reduction in symptomatic UTI, sepsis, or mortality)

Special Population: Elderly and Long-Term Care Residents

Asymptomatic bacteriuria occurs in 15-50% of elderly patients and should NOT be treated. 1, 3

Evaluation is indicated ONLY with acute onset of 1, 3:

• Fever >38.3°C
• New or worsening urinary incontinence
• Dysuria, frequency, or urgency
• Gross hematuria
• Suspected bacteremia with no other source

Mental status changes, falls, or functional decline alone do NOT justify UTI treatment—these symptoms have NOT been shown to improve with antibiotics and treatment increases harm. 1

Special Population: Catheterized Patients

Never screen for or treat asymptomatic bacteriuria in patients with indwelling catheters—bacteriuria is universal and treatment provides no benefit. 3, 2

Treat catheterized patients ONLY if 3:

• Fever >38.3°C
• Rigors or hemodynamic instability
• Suspected urosepsis

Replace catheters that have been in place ≥2 weeks before obtaining culture, as biofilms prevent accurate assessment. 2

Follow-Up

No routine post-treatment urinalysis or culture is needed for asymptomatic patients who respond to therapy. 1

Obtain repeat culture if 1:

• Symptoms do not resolve by end of treatment
• Symptoms recur within 2-4 weeks
• Patient has recurrent UTIs requiring documentation